Black patients with terminal cancer more likely to choose aggressive care at end of life

Holly Gwen Prigerson, PhD. Dana-Farber Cancer Institute. 44 Binney Street. Shields Warren 440A. Boston, MA 02115. Office phone: (617) 632-2369. Appointment phone: (617) 632-2369. Fax: (617) 582-8017, E-mail: Holly_Prigerson@dfci.harvard.edu Dr. Prigerson has studied psychosocial factors that influence the quality of life and care received by terminally ill patients and factors influencing caregiver adjustment both before and after the death of a loved one since her dissertation work at Stanford in the late 1980s. She completed a postdoctoral fellowship in the Epidemiology of Aging at Yale University and then was funded by the NIMH for a K-award to study psychosocial factors in bereavement-related depression while an Assistant Professor of Psychiatry at Western Psychiatric Institute and Clinic in Pittsburgh. Dr. Prigerson moved to Dana-Farber Cancer Institute to assume leadership of the Center for Psychooncology and Palliative Care Research, with an academic appointment as Associate Professor of Psychiatry at Brigham and Women's Hospital, Harvard Medical School. She is now involved with a wide variety of research projects including intervention studies for Complicated Grief, a study to improve the cardiovascular health of recently bereaved cancer patient caregivers, and the factors influencing equanimity in the acknowledgement of terminal illness.

CHICAGO—Black patients with advanced cancer were more likely than whites to die in a hospital intensive care unit, reflecting a greater preference among blacks for life-extending treatment even in the face of a terminal prognosis, according to a study led by researchers at Dana-Farber Cancer Institute in Boston. The findings (abstract 6506) will be presented at the annual meeting of the American Society of Clinical Oncology in Chicago on Monday, June 2, 3 - 6 p.m. CT, South Building, Hall100B. The report included interview data showing that blacks more often answered yes to questions such as, "Would you want the doctors here to do everything they can to keep you alive, even if you were going to die in a day or two?" "This is the first study focused on black/white differences that prospectively asked [terminal cancer patients] what kind of care they wanted at the end of life, and then documented the kind of care they actually received and the place of their death," said Elizabeth Trice, MD, PhD, of Dana-Farber, lead author. Although they ruled out a number of possible explanations for the black/white differences, the investigators weren't able to identify precisely why blacks tended to prefer more-aggressive care. "There is something different about the way black patients and white patients approach the end of life," Trice said, which may be based in cultural attitudes, religious beliefs, and how thoroughly they have been informed about and comprehend their prognosis, among other things. Data on the preferences was obtained from the Coping with Cancer study led by Holly Prigerson, PhD, director of the Center for Psycho-social Oncology and Palliative Care Research at Dana-Farber and an associate professor of psychiatry at Harvard Medical School. That study is recruiting 800 cancer patients and their informal caregivers, such as family members. The researchers recorded the location of death for 231 white and 61 black patients who had stage IV metastatic cancer, and who had been interviewed when they entered the study. Black patients were over four times more likely to die in a hospital ICU than white patients, they found.

The researchers, using multivariable models, found that the increased likelihood of dying in the ICU for black compared to white patients was not explained by differences in education, physical or mental health, insurance, social support, doctor-patient communication, or advance care planning, when taking into account the patient's own preference for more-aggressive care. It was clear that a patient's preference for aggressive care was the strongest factor in predicting death in an ICU.

In their initial interviews, black patients reported having a higher quality of life than their white counterparts and appeared more at peace, Trice said, which could be a factor in opting for a treatment plan aimed at extending life.

Prigerson, the senior author of the study, said the crucial question to be explored is whether the treatment preferences that explain the black/white disparities in ICU death are informed preferences or not. Toward that end, Trice has developed a research tool for assessing patients' knowledge of risks and benefits of life-extending therapies. If further research determines that blacks and whites are not equally well-informed about these risks and benefits, interventions aimed at eliminating this disparity should be considered, said the scientists. ###

The study's co-authors are Matthew Nilsson, Alexi Wright, MD, Tracy Balboni, MD, K. "Vish" Viswanath, PhD, and Karen Emmons, PhD, of Dana-Farber; Susan DeSanto-Madeya, RN, DNS, of the University of Massachusetts, Boston; and M. Elizabeth Paulk, MD, and Heather Stieglitz, PhD, of the University of Texas Southwestern Medical Center, Dallas.

Dana-Farber Cancer Institute (www.dana-farber.org) is a principal teaching affiliate of the Harvard Medical School and is among the leading cancer research and care centers in the United States. It is a founding member of the Dana-Farber/Harvard Cancer Center (DF/HCC), designated a comprehensive cancer center by the National Cancer Institute.

Contact: Bill Schaller william_schaller@dfci.harvard.edu 617-632-5357 Dana-Farber Cancer Institute